Provider Relationship and Network Contracting Manager

TakeCare Insurance Company, Inc. • Tamuning, GU

1d

About The Position

Reports directly to the Health Plan Administrator and responsible for provider contracting with physicians, hospitals/facilities and ancillary providers for all contracts pertaining to health plan including PPO, lease networks, workers’ compensation, third party administration and medical travel. Performs ongoing network analysis to ensure network adequacy and responsible for contracting with individual providers who meet established selection criteria to assure adequate geographic and specialty coverage, and makes recommendations for retention or delistment of providers to the Health Plan Administrator.

Requirements

• Graduate of Bachelor’s Degree – License is not required
• Minimum of 3 years’ experience in provider contracting with physicians, hospitals, facilities, clinics and ancillary providers for all contracts pertaining to health plan including PPO, lease networks, workers’ compensation, third party administration and medical travel. Performs ongoing network analysis to ensure network adequacy and responsibility for contracting with individual providers who meet established selection criteria to assure adequate geographic and specialty coverage and makes recommendations for retention, termination or delistment of providers.
• Knowledge of health care industry coding guidelines and standards.
• Effective team player. With very good interpersonal relationship skills and can work and relate well with network providers and physicians.
• Must have the behavioral sensitivity, maturity, diplomacy and tact in addressing complex situations and handling diversity of customers and providers.
• Outstanding oral and written communication skills.
• Strong ethics and a high level of personal and professional integrity.
• Must have basic familiarity with federal and state laws and requirements relating to healthcare management.
• Computer literate and very highly proficient in using MS office programs.

Responsibilities

• Provider Relations
• Develops, maintains and manages an effective relationship between TakeCare and its network of providers, both on island and off island. Serves as main contact and liaison between provider network and TakeCare. This includes responsibilities related to establishing and maintaining an effective and viable provider network of doctors, dentists, hospitals, facilities, laboratories, clinics, medical specialists, and other healthcare professionals.
• Coordinates with the Health Plan Administrator in designing, developing and implementing strategies, plans and programs in negotiating, developing and designing contractual provider arrangements including contract terms and conditions and pricing methodologies.
• Evaluates contractual payment methodologies in order to determine financial risk to TakeCare and provider (per diem, capitation, discount from charge, DRG, case rate, etc.).
• Ensures the design, production and distribution of financial, utilization and customer service information and the production and completeness of annual utilization/financial reports as they relate to contracted provider performance.
• Interfaces between the plan’s financial department and other plan administration teams for budget, financial reporting, claims processing & payments and settlement arrangements.
• Reviews and evaluates quantitative analyses for various financial and clinical data as basis for recommending effective contractual decisions and responsible for providing performance of ongoing contractual arrangements to appropriate parties.
• Works directly with the claims department to resolve and correct contract setup, claim coding errors based on provider and facility contracts, payments and claims reconciliation with provider network.
• Interacts directly with network and non-network providers on contract and administrative related areas to bring full resolution to the issues and inquiries they bring.
• General Management
• Planning
• Develops plans and programs for Provider Relations team and ensures that goals and objectives of the team are properly defined and clearly established.
• Develop policies, guidelines, and implement procedures and ensure consistent company-wide implementation.
• Develop budgetary plans, programs, and guidelines to ensure the team’s strict adherence with financial guidelines and requirements.
• Ensures that operating expenses are well within the prescribed limits of budget plans and fiscal guidelines.
• Organizing
• Develops the appropriate organization structure for the Provider Relations and Network Contracting team.
• Delineates, defines, and streamlines its various functional activities, thereby ensuring its effectiveness in maximizing the utilization of both asset and people resources.
• Leading
• Performs selection and staffing functions such as:
• In collaboration with Human Resources Department, conducts in-depth assessment interviews to determine the technical and behavioral competencies of the candidate to ensure that the best from among the qualified candidates are being hired in the company.
• Adheres to and implements the philosophy of “hiring the best fit” and ensures that prospective employees’ personal values are aligned with the company’s corporate values.
• Conducts regular and periodic meetings with the team, to ensure the following:
• Implementation of all Provider Relations and Network Contracting plans, programs, and projects are strictly adhering to prescribed deadlines and schedules.
• All communications and relevant information pertaining to the team are cascaded to the proper channels within the team in particular, and the organization in general.
• Conducts and implements “Performance Improvement Program”, through the following:
• Performance coaching for the staff who failed to perform and deliver the prescribed and committed level of performance output and standards.
• Performance counseling staff with behavioral/attitudinal problems. Implements the necessary guidelines on discipline management for erring employees, in accordance with company policies, rules and regulations, due process, and government regulations.
• Performance mentoring for high potential staff, capable of assuming bigger responsibilities in the future.
• Performs training and development functions, as follows:
• Designs and develops training programs that are relevant and necessary for the continuous development of the technical competencies of the team.
• Recommends and implements for appropriate training programs that will further enhance and hone the technical competencies of the staff.
• Conducts training programs and acts as subject matter expert on training programs pertaining to Provider Relations and Network Contracting.
• Controlling
• Develops and formulates performance measures and standards for the team, as basis for the conduct of annual performance management review program.
• Reviews and evaluates the performance of the team, on regular and periodic basis, and ensures that the overall performance of the team is on track, and well within the pre-established goals and objectives.
• Consolidates performance status reports of the team as basis for monitoring the weekly progress of the various activities within the team.

What This Job Offers

• Career Level: Manager